Hair Transplantation to the Eyebrow, Eyelashes, and Other Parts of the Body
By Jeffrey S. Epstein, MD and Marcelo Gandleman, MD

• Synopsis
• Introduction
• Reconstruction of Eyebrows and Eyelashes
• History
• Etiology
• The Consultation
• Designing and Restoration
• Surgical Technique
• Reconstruction of the Sideburn, Moustache, and Beard
• Chest Hair Transplantation
• Restoration of The Pubic Escutcheon

Authors:
Marcelo Gandleman, MD
Private Practice, Brazil

Jeffrey Epstein, MD, FACS
Associate Clinical Professor, University of Miami College of Medicine,
Department of Otolaryngology

SYNOPSIS:
Since its earliest applications, hair transplantation has been utilized for treating not only the scalp in pattern baldness, but also other parts of the body, commencing with eyebrow reconstruction. The earliest micrografts were applied to the eyebrow, more than 30 years before their application to the scalp became the standard of care.
While the popularity of hair transplantation today is largely a testament to the quality of results attainable for the treatment of male and female pattern hair loss, it can, and is, applied to a number of other areas. The principle behind transplanting these areas is the same- once transplanted, the hairs continue to grow due to the phenomenon of donor dominance. Presented is a review of the role and technique of hair transplantation to the eyebrows and eyelids, chest, beard and moustache, and pubic escutcheon

INTRODUCTION
Since its earliest applications, hair transplantation has been utilized for treating not only the scalp in pattern baldness, but also other parts of the body, commencing with eyebrow reconstruction. The earliest micrografts were applied to the eyebrow, more than 20 years before their application to the scalp became the standard of care.(1-3)
While the popularity of hair transplantation today is largely a testament to the quality of results attainable for the treatment of male and female pattern hair loss, it can, and is, applied to a number of other areas. The principle behind transplanting these areas is the same- once transplanted, the hairs continue to grow due to the phenomenon of donor dominance. What follows is a review of the role and technique of hair transplantation to the eyebrows and eyelids, chest, beard and mustache, and pubic escutcheon.

RECONSTRUCTION OF EYEBROWS AND EYELASHES
Bald people are considered normal and healthy human beings, and have the option of staying bald. However, madarosis, the absence of eyebrows or eyelashes, can be an unnatural, humiliating characteristic, attracting curiosity, causing social discomfort, and adversely affecting self-esteem and professional and romantic relationships. It is said that the eyes are the window to the soul, reflecting our state of mind. We actually believe that eyebrows create the expressions attributed to the eyes, such as surprise, fear, and rage, and that eyelashes are responsible for the sensual look, with blinking Mother Nature’s way of flirting.

On a functional basis, the absence of eyebrows and eyelashes makes the eyes more vulnerable. Eyebrows keep forehead perspiration away from eyes, and with squinting, facilitate the blocking of bright sun. Eyelashes keep dust and foreign bodies from the eyes, and initiate the blink reflex.

In restoring anatomy, eyebrow and eyelash reconstruction surgery restores function, improves appearances, and elevates patients’ self esteem.

HISTORY
In 1914, Krusius rebuilt eyelashes harvesting scalp grafts with small punches, then transplanting them to the ciliary border with the same punch.(4) Knapp in 1917 developed the technique of inserting a free strip graft from the eyebrow along the eyelid border.(5) Sasagawa in 1930 reported the method of hair shaft insertion.(1) Fujita in 1953 reconstructed eyebrows by punctiform hair grafting using an injection needle.(6-8) In 1980, Marritt transplanted follicular roots extracted from the periphery of 4 mm circular punches, inserting them in the eyelid border with a needle.(9-11)

Other described methods of eyebrow reconstruction include free or pedicled strip hair grafts from the scalp or the contralateral eyebrow (12), temporal artery island flaps (13, 14), and punch hair transplantation.(15) For eyelid reconstruction, other described methods include strip grafts from the eyebrows, pedicled flaps from the eyebrows, and strip sideburn grafts.(16)

At present, we use single, and occasionally double hair grafts obtained through follicular unit dissection, harvested from the scalp.

ETIOLOGY:
Loss of eyebrows and eyelashes can have a number of etiologies. The most common is that from trauma, such as avulsions and burns, and complications from tattooing and infections, where scarring results in areas of alopecia. The recent popularity of body piercing has been associated with cases of alopecic scarring following infection of piercing channels. Scarring from tumor surgery, radiation therapy, and inadvertently placed incisions of direct browlift surgery can all produce alopecia. Long term electrolysis or plucking, or overzealous laser hair removal can result in thinned or absent eyelashes or eyebrows. Trichotillomania, an obsessive-complulsive disorder characterized by repeated hair pulling over a series of years, and a variety of dermatologic diseases (17) must also be considered and, if necessary, treated. Finally, endocrinopathies, such as hypothryodism , which can be treated, and congenital aplasia are also common causes.

THE CONSULTATION:
The role of the consultation is patient education and assessment of the patient’s appropriateness for surgery. It is a time for the surgeon to provide realistic expectations, as well as to investigate for potential etiologies of the hair loss, learn the goals of the patient, and assure that there are no contraindications for surgery. In many cases, because the patient does not consider this procedure as “real” surgery, there is a risk that some of the medical history will not be provided.(18) A thorough medical history and examination should be focused on finding contributing etiologies to the hair loss.

While rare in the eye region, individuals prone to excessive scarring or to keloid formation should be advised of the risk, and closely watched in the post-procedure period. The patient must be completely recovered from dermatologic diseases such as discoid lupus and alopecia areata, including obtaining clearance for the procedure by a dermatologist. Psoriasis is not a contraindication for surgery.(18,19)

Hypertension and diabetes, while not contraindications for surgery, should be under clinical control. Cases of untreated or poorly treated hypothyroidism should be evaluated by an endocrinologist to reduce the chance of further loss of eyebrow hair. A patient with trichotillomania or psychiatric illness should have clearance from a psychiatrist.

If desired, preoperative screening tests can include prothrombin and partial thromboplastin times (PT and PTT), platelet count, and CBC. In nearly all cases, a thorough history is much more accurate than a battery of expensive lab tests in detecting any bleeding risks. If such risks are detected, a bleeding time is probably the most accurate for objective measurement. Tests for HIV and hepatitis can be included according to the community’s standard of care. Because of the risk of graft popping and hematoma formation, patients are advised to avoid aspirin and vitamin E for 10 days, and alcoholic beverages and anti-inflammatories for 3 days prior to surgery. Vitamin C 1000 to 2000 mgs a day for 10 days may help reduce bruising.

Patients with permanent makeup of the eyebrows and/or eyelashes are good candidates for surgical reconstruction. The tattoo does not interfere with graft integration, and provides a background shade after surgery, enhancing the appearance of density. Patients who receive transplants are advised of the further enhancement that can be achieved by undergoing permanent makeup to the area.

While not legal in the United States, in most other countries the implanting of nylon threads for baldness and other hair reconstruction is legal. Patients with nylon eyebrow implants usually have a chronic inflammation/infection, with scar sequelae. Prior to definitive surgery, all remaining nylon remnants must be removed, and full recovery from the infection confirmed.

DESIGNING AND RESTORATION
With the patient seated, the most natural design is marked out. With the patient’s input, the limits of the proposed grafting can be altered to provide wider or narrower, and shorter or longer coverage. Glamorous or stylish designs are typically avoided, as the goal is to follow the natural anatomical patterns.

The female eyebrow is typically more cephalic to the orbital rim, with a mild to moderate arched shape that is most cephalic at a point superior to the lateral limbus.(Figure 1) The male eyebrow is typically lower and less arched, with a straighter appearance, together with the nose forming a “T”, with the horizontal limbs composed of the eyebrows and the vertical limb a line drawn along the midpoint of the nose in its axis.(Figure 2) Attention to the fluctuating direction of growth of the hairs is essential to help assure a natural appearance. Medially, the hairs in the natural eyebrow grow vertically in a cephalic direction, while laterally, the more cephalic hairs grow somewhat laterally and caudally, while the more caudal hairs grow somewhat laterally and cephalically, in a cross-hatched pattern. While it is important to incorporate these guidelines, the best results are usually attained when the recipient sites are made such that the direction of hair growth is not so cephalic or caudal, but rather more horizontal/lateral. In addition, the angle of growth from the skin is minimal, so that the hairs are basically growing flat along the surface, rather than sticking out from the face.

With the eyelashes, there is much less variation in direction and angle of growth. The goal is to have the hairs grow away from the leading edge of the eyelid. Often the patient needs to use a curler to direct the hairs in the proper direction of growth. Photographic documentation of the markings, showing the plan for restoration, are necessary.(20)

SURGICAL TECHNIQUE

Preparation and Design

The night before and morning of the procedure, the patient is to wash the face and hair with an antiseptic soap. A light meal prior to the procedure is recommended, especially if the patient is to receive oral sedation. Our choice of sedation is a benzodiazepine, such as diazepam, and sometimes a hypnotic like Ambien® (zolpidem tartrate). In addition, some surgeons prescribe antibiotics perioperative and for 3 days post-operative.

Local anesthesia of 2% lidocaine with 1:100,000 epinephrine, in minute amounts, is injected. The use of the Wand® (Milestone Scientific Inc, Livingston, NJ) can help reduce the discomfort of injection. Betadine prep is usually preferable to that done with antiseptics like chlorhexidene with which there is a risk of corneal damage.

Donor Material

Once anesthetized, the donor material is excised, either as a single fusiform shaped strip which is sutured closed, or extracted as individual follicles using tiny 1 to 1.5 mm punches into the donor area, using the more recently developed technique of follicular unit extraction and avoiding the need for sutures. At our earliest surgeries, we attempted to transplant the most delicate hair of the nape of the neck or of the temporal region just behind and/or above the ear, believing that these thinner hairs would provide a finer, more natural appearance.(21) With time, it became clear that there is no difference when slightly thicker hairs are utilized from those areas or from the mid-occipital region. Some authors have noted that hairs transplanted to eyebrows, legs, and potentially other areas of the body may grow with a diameter smaller than they had in the donor area, suggesting some role of recipient site dominance. It has been personally observed that transplanted eyebrow hair undergoes a type of metaplasia in its new location, producing a more harmonious and favorable final result.
Dr. William Parsley has measured the diameters of scalp and eyebrow hairs with an optical micrometer. He demonstrated that, in Asian patients, scalp hair is actually thicker than eyebrow hair, while in Caucasians, the opposite is true- eyebrow hairs have a larger diameter than scalp hair.(22)
For the eyebrow, the single fusiform-shaped ellipse of donor tissue need not measure larger than 1 by 3 cms, which should provide at least 250 follicular unit grafts. This number is usually sufficient for restoring both eyebrows, and can be adjusted downward if less work is to be performed. Closure of the donor site is accomplished with a simple running 3-0 polypropylene (Prolene; Ethicon Inc, Sommerville, NJ) suture. The follicular unit grafts will each contain 1, and if the surgeon deems, 2 hairs. Dissection of each graft is performed under microscopic visualization so as to assure the inclusion of a minimal amount of surrounding skin.(23) For the eyelashes, most surgeons advocate the removal of virtually all surrounding skin, leaving just the actual hair and follicle. These eyelash grafts can be created by stripping away the surrounding skin with a jeweler’s forceps.

Recipient Sites and Graft Placement

The incisions are made along the markings as close together as possible. A variety of instruments are available for this step- a 20 or 21 gauge needle, or a microblade 0.7 or 0.8 mm in size, custom cut from a single edge razor blade, are appropriate. Direction and angle of recipient sites should closely parallel the direction of natural hair growth, to the degree described above. An average of 100 grafts are transplanted to each eyebrow, but can be adjusted up or down depending upon the amount of eyebrow to be restored.

Grafts are then atraumatically placed into the recipient sites. The finest 1 hair grafts are reserved for the edges, especially superior and lateral. Once transplanted, no dressing or other special preparation is applied. The patient may leave the office, wearing glasses if desired, and careful washing may resume 2 days later. Figure 3 illustrates the steps of an eyebrow restoration procedure.

For the eyelashes, a topical anesthetic is applied to the eye(s), and then a corneal eye protector is placed. There are several methods of recipient site formation and graft placement. In one, the hair thread is inserted into the hole of a French needle, creating in essence a suture. The needle is inserted in the eyelid skin and brought out at the inferior tarsus border where the eyelashes emerge. The root slides into the hole following the needle, leaving the follicle in place (Figure 4). Another technique is to make very tiny (21 gauge needle or 0.7 microblade) incisions along the tarsal border, then insert the grafts retrograde as with conventional hair graft placement. Finally, another technique utilizes the placement of a one-follicle wide strip of hair obtained from the sideburn region into an undermined pocket of surrounding skin through an incision made along the tarsal border. The graft is secured in position by one or more 6-0 nylon sutures.(16) One advantage of this technique, according to its authors, is that it can be used for eyelash augmentation.

Because of the risk of trichiasis, procedures in the lower eyelid must be done with caution, and the patient advised as to this risk.

After Care

To avoid dislodging the grafts, for the first night the patient can sleep wearing glasses or with the eye/brow lightly patched. Ice applied for the first 48 hours can prevent edema. Pain is managed with mild analgesics, and most surgeons prescribe antibiotics. For the eyelashes, an ophthalmic ointment or gel is recommended until the crusts fall off.

Not infrequently, the transplanted hair grows immediately after surgery. The patient must trim the eyebrow and eyelash hairs every 2 to 4 weeks. An eyelash curler can be helpful to control direction of hair growth. For the eyebrows, training of the hairs to grow in the desired direction can be undertaken by the application of a gel or ointment for the first several months.

While eyebrow hairs have a survival rate typically 90% or greater, eyelash grafts have a growth rate as low as 50%. This loss is probably due to the extra manipulation of the hairs, and can be compensated for by the transplanting of additional grafts.

RECONSTRUCTION OF THE SIDEBURN, MOUSTACHE AND BEARD
Sideburns represent the extension of scalp hair from the temporal region to the pre-auricular region in women, and connecting with the beard in men. The primary etiology for absence of this facial hair in women is post-surgical, following a facelift in which the vector of pull is superior/posterior. This can usually be avoided by using a facelift approach that extends the preauricular incision from the helical root in an anterior horizontal direction through the sideburn, rather than one that is in a more superior vertical direction through the temporal scalp. Because of its superiority in improving the cosmesis of the lateral brow region, the latter orientation that often results in hairline distortion is commonly chosen by many plastic surgeons. For the beard and moustache region, congenital absence or thinning are the most common etiologies, while scarring from cleft lip surgery or other trauma such as burns, are also seen.
A variety of surgical techniques have been described for sideburn restoration.(15,24-38 ) and moustache/beard restoration.(39-45) Our technique of choice is that of transplanting with 1 and 2 hair follicular unit grafts

Surgical Technique

Preparation and Design
The design of the restoration is marked out on the patient. For the sideburn, the key to achieving a natural appearance is the use of the finest 1-hair grafts along the leading anterior and inferior edges, where the direction of growth is caudal and posterior, especially inferior towards the tragus. (Please refer to the article on hair transplantation in women which appears in this Clincs) In the beard and moustache, the direction of growth is essentially caudal, somewhat anterior along the upper cheek region, with an angle closely parallel to the skin.
Anesthesia is somewhat difficult to achieve, due to extensive nerve supply of the facial region. Mental and infraorbital nerve blocks only serve parts of the face, requiring local anesthetic to be injected over much of the rest of the areas to be transplanted.

Donor Material

The donor material comes from the occipital and, if desired or needed, temporal scalp. A single fusiform shaped strip is excised and the donor area reapproximated with a 3-0 polypropylene suture. The size of the donor strip is determined by the number of grafts to be transplanted. Complete restoration of one sideburn is typically achieved with 150 to 200 grafts, but this number can be larger depending upon how high the defect extends. For the beard and/or moustache, it is not uncommon to transplant as many as 1600 to 1800 grafts. Natural results are achieved with 1 and 2 hair grafts for these areas. In many patients desiring beard/moustache restoration, the concentration of grafts is usually desired in the goatee (perioral) region. Attention must be paid as to the natural concave curvature of the superior border of the beard in the infra-oral region as it extends caudally from the oral commissure in a vertical direction, to a more horizontal direction along the cephalic edge of the mental crease, returning to a vertical direction in the central lower lip.

Recipient Sites and Graft Placement

Recipient sites are made with one of several instruments. 21 or 22 gauge needles or 0.8 to 1.0 mm microblades are appropriate. As discussed above, the angle and direction of the recipient sites are important in achieving a natural appearing result. The microscopically dissected grafts are then atraumatically implanted into the recipient sites (see Figure 5).

After Care

Caution with the grafts must be taken the first 48 hours. After this time, there is little risk of graft loss, and gentle face washing may be resumed. All crusts should fall off by 7 days, after which cautious shaving may be performed.

CHEST HAIR TRANSPLANTATION
A particularly interesting area of transplantation, given the recent trend towards the freedom from body hair, is chest hair transplantation. It is our experience that these patients have legitimate, realistic goals, and are quite happy with their results.
Like with the eyebrow and eyelashes, the scalp hair transplanted needs to be trimmed once or twice monthly. The design of the restoration is such that the concentration of hairs is along the central or sternal region, with hairs extending outwards along the chest, often extending lateral to the areola, and down around this important anatomical landmark. At times patients may desire extension of the restoration to the abdomen, to as low as the pubis, where it is usually best to concentrate grafts in the midline.

The direction of hair growth is typically medial and inferior, with the most central hairs cross-hatching with each other along the sternum so as to form a thicker density. Peri-areolar, the direction of growth is usually circular. The angle of growth is flat, parallel to the chest skin. Figure 6 illustrates the overall pattern of chest hair growth used for transplantation.

Perhaps the biggest challenge in chest hair transplantation is achieving anesthesia. Because there is diffuse cutaneous innervation that derives from deep and superficial nerves, the entire chest region to be transplanted needs to be injected superficially with local anesthesia. Because of the large quantities of agent required, patients will usually receive intravenous fluids, and areas are injected regionally with intervals between injections to avoid lidocaine toxicity. To reduce the discomfort of injection, it is helpful to apply topical anesthetics and ice, and, if desired, intravenous sedation is provided.

The donor area is the occipital and frequently temporal scalp, to allow the taking of a large enough donor strip. Typical procedures consist of 2000 or more 1 and 2 hair follicular unit grafts, with smaller numbers utilized for less coverage. Recipient sites are created with 20-degree needles or 1.0 to 1.1 mm chisel blades. The grafts are then carefully inserted. Post-procedure care is minimal. Showering is permitted after 48 hours, and the crusts are expected to fall of within one week.
Hair growth typically resumes at 3 to 4 months. Trimming of these original scalp hairs is usually needed once or twice a month (see Figure 7).

RESTORATION OF THE PUBIC ESCUTCHEON:
Tanaka in 1999 described the use of a free temporoparietal fasciocutaneous flap for reconstructing the pubic region.(46) However, since the beginning of hair transplantation, Japanese surgeons have successfully used 1, 2, and 3 hair grafts for reconstruction of this region.(47,48)

REFERENCES:
1. Sasagawa M. Hair Transplantation. Jpn J Dermatol (Japanese) 30:493, 1930.
2. Okuda S. Clinical and experimental studies of transplantation of living hairs. Jpn J Dermatol (Japanese) 46:135-138, 1939.
3. Fujita K Reconstruction of eyebrow. La Lepro (Japanese) 22:364, 1953.
4. Krusius F. Ueber die Einplflanzung Lebender Haare zur Wimpernbildung. Dtsch. Med. Wockenschr, 1914. 19: p. 958.
5. Knapp P. Klin Mbl Augenheilk, 1917. 59: p. 447.
6. Fujita, K., Reconstruction of Eyebrows. La Lepro, 1953. 22: p. 364.
7. Arakawa, I., [Single hair transplantation for eyebrow]. Keisei Geka, 1965. 8(2): p. Suppl:8-11.
8. Ishiko, S. and M. Kanazashi, [Repair of eyebrow. (Single hair transplantation using Kamazashi's needle)]. Keisei Geka, 1965. 8(2): p. Suppl:11-5.
9. Marritt, E., Transplantation of single hairs from the scalp as eyelashes. Review of the literature and a case report. J Dermatol Surg Oncol, 1980. 6(4): p. 271-3.
10. Marritt, E., Single-hair transplantation for hairline refinement: a practical solution. J Dermatol Surg Oncol, 1984. 10(12): p. 962-6.
11. Unger, W.P., Eyelash Transplantation, in Hair transplantation, W. Unger, Editor. 1995, M. Dekker: New York. p. 309.
12. Pensler, J.M., Dillon, Band Parry, S.W., Reconstruction of the eyebrow in the pediatric burn patient. Plast Reconstr Surg, 1985. 76(3): p. 434-40.
13. Kissane, D.W., et al., [Eyebrow reconstruction by a scalp island flap based on the frontal branch of the superficial temporal artery]. Chung Hua Cheng Hsing Shao Shang Wai Ko Tsa Chih, 1996. 12(1): p. 25-7.
14. Ma, G., P. Yang, and J. Luan, [Eyebrow reconstruction by a scalp island flap based on the frontal branch of the superficial temporal artery]. Chung Hua Cheng Hsing Shao Shang Wai Ko Tsa Chih, 1996. 12(1): p. 25-7.
15. Nordstrom, R.E., Sideburn reconstruction. Plast Reconstr Surg, 1991. 88(6): p. 1107-8.
16. Hernández Zendejas, G. and Guerrerosantos, J., Eyelash reconstruction and aesthetic augmentation with strip composite sideburn graft. Plast Reconstr Surg, 1998. 101(7): p. 1978-80.
17. Guerrero-Santos, J., A. Casteneda, and J.M. Fernandez, Correction of alopecia of eyebrows in leprous patients. Plast Reconstr Surg, 1973. 52(2): p. 183-4.
18. Gandelman, M., Eyelash Reconstruction. Hair Transpl Forum Int, 1996. 6(5).
19. Gandelman, M., Eyelash Reconstruction and Aesthetic Augmentation, in Hair Transplantation, A. Barrera, Editor. 2002, Quality Medical Publishing, Inc.: St. Louis, Missouri. p. 168.
20. Haber, R.S., Standadized Photography for hair restoration, in Hair Replacement: Surgical and Medical, D.B. Stough and R.S. Haber, Editors. 1996, Mosby: St. Louis. p. 41.
21. Gandelman, M., Eyebrow and eyelash transplantation, in Hair Transplantation, W.P. Unger, Editor. 1995, M. Dekker: New York. p. 294.
22. Parsley, W., Personal communication. 2003.
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31. Juri, J., C. Juri, and J. de Antueno, Reconstruction of the sideburn for alopecia after rhytidectomy. Plast Reconstr Surg, 1976. 57(3): p. 304-7.
32. Juri, J., Sideburn reconstruction in secondary lifting. Plast Reconstr Surg, 1998. 102(6): p. 2241-3.
33. Karacalar, A., The use of an island scalp flap based on the superficial temporal artery for the reconstruction of the sideburn. Plast Reconstr Surg, 2000. 105(5): p. 1899.
34. Kasai, K., Y. Ogawa, and E. Takeuchi, A case of sideburn reconstruction using a temporoparieto-occipital island flap. Plast Reconstr Surg, 1991. 87(1): p. 146-9.
35. Rodriguez-Camps, S., Reconstruction of sideburn and temporal area after a face lift. Aesthetic Plast Surg, 2002. 26(3): p. 181-3.
36. Sebben, J.E. and R.I. Ceilley, Reconstruction of a sideburn by a rotated flap. J Dermatol Surg Oncol, 1979. 5(6): p. 484-5.
37. Sylaidis, P., A. Poppatt-Hadden, and T. Adams, One-stage sideburn reconstruction with hair-bearing scalp based on the retroauricular branch of the superficial temporal vessels. Ann Plast Surg, 2000. 44(6): p. 679-80.
38. Nordstrom RE, Greco M, Vitagliano T. Correction of sideburn defects after facelift operations. Aesthetic Plast Surg, 2000. 24(6); 429-432.
39. Brandy DA. Chest hair used as donor material in hair restoration surgery. Dermatol Surg 1997. 23(9); 841-844.
40. Agrawal K, Panda KN. Moustache reconstruction using an extended midline forehead flap. Br J Plast Surg 2001 54(2); 159-161.
41. Kumar P. L-shaped scalp flap for moustache reconstruction in a patient with an acid burn of the face. Burns 1996. 22(5); 413-416.
42. Reed ML, Grayson BH. Single-follicular-unit hair transplantation to correct cleft lip moustache alopecia. Cleft Palate Craniofac J 2001. 38(5);538-540.
43. Vallis CP. Hair transplantationto the upper lip to create a moustache. Case report. Plast Reconstr Surg 1974 54(5);606-608.
44. Barrera A. Restoration of the eyebrows, mustache and beard. In Hair Transplantation, A Barrera editor 2002. Quality Medical Publishing Inc; St Louis, Missouri. p. 158.
45. Navarro-Ceballos R, Bastarrachea RA. Clinical applications of temporoparietal hair-bearing flaps for male pattern baldness and mustache formation. Aesthetic Plast Surg 1991. 15(4);343-348.
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47. Tamura H. (Pubic hair transplantation). Jpn J Dermatol 1943. 53:p. 76.
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Legends
Figure 1: The “ideal” feminine eyebrow. Note the arched appearance with the peak at a point directly above the lateral limbus.
Figure 2: The “ideal” male eyebrow. Note the flatter appearance than the female version.
Figure 3: 30 year old female with significant loss of eyebrow hair with etiology both congenital and secondary to plucking. Before (A), before with the area of the restoration marked out (B), immediately after (C), and 1 week after (D) 200 grafts.
Figure 4: Illustration of the needle insertion technique in eyelid transplantation.
Figure 5: 38 year old male with congenital weakness of beard hair. Before (A), intra-op (B), and 8 months after (C) 1400 grafts. Note the flat angle of the blade for the creation of recipient sites that will allow the hairs to grow along the natural direction.
Figure 6: Illustration of the natural direction of chest hair growth that can guide transplantation.
Figure 7: 34 year old male with congenital absence of any significant chest hair. Before (A), intra-op (B), and 8 months after (C) the third procedure. A total of 6500 grafts were transplanted.

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